Professional Issues Flashcards
Malpractice insurance role ?
is to cover costs that are associated with obtaining legal defense when a practitioner is being sued.
There are 2 types of malpractice insurance policies:
Occurrence policies
Claims-Made policies
Claims-made policies coverage explanation:
provide coverage only during the time that the insured is paying the premium.
Occurrence policies cover the insured for
all the potential claims made at any time during the policy period, even if the insured no longer work at the same place, or have changed insurance policies or has retired.
As far as the CRNA goes what is essential?
It is essential to obtain a tail policy for a minimum order number of years (5 usually) after a claims-made policy has ended.
What is an umbrella policy?
Obtained in addition to the tail policy. Useful if damages or settlement exceeds the limits of the original policy damages.
What kind of policy requires a tail coverage?
Claims-based policies
Tail policy protect
the insured for a PREDETERMINED PERIOD OF TIME after the policy has ended.
Which principle asserts that a provider has an obligation not to inflict hurt or harm
Nonmaleficence
Hippocratic oath primum non nocere meaning?
First do no harm
T/F There is no distinction between intentional or unintentional harm.
True
The use of unnecessary preoperative testing can put the provider in violation of the principle of
nonmaleficence.
Principles that govern human conduct as it relates to morality, right and wrong, or good and evil.
Ethics
Comprise the set of moral principles, beliefs, and values that guide how choices are made in health care.
Health care ethics
Commonly accepted principles of health care ethics include:
Respect for autonomy
Nonmaleficence
Beneficence
Justice
Refers to the patient’s ability to choose without controlling interference by others, and without limitations that prevent meaningful choices.
Autonomy
Might include failure of the provider to fully provide information that a reasonable person would want to know prior to making a decision during the informed consent process.
Autonomy
Respect for autonomy means that providers must
respect and abide by decisions made by competent patients.
Respect for autonomy dictates that providers make every effort to
remove barriers that may impede an informed decision.
Principle asserts that a provider has an obligation not to inflict hurt or harm—in other words, the Hippocratic oath primum non nocere (first do no harm).
Non-maleficence
This principle is often applied to the appropriate use of diagnostic testing with the inherent risk of false-positive or false-negative results.
Non-maleficence
For example, the use of pre-operative HIV testing has serious social costs and adds little or nothing to the anesthesia care plan or expected surgical outcome.
Non-maleficence
In another example, requiring a pregnancy test in every female of child bearing age is not justified by evidence-based research, and violates patient _____in the absence of consent.
autonomy
Some diagnostic testing has inherent medical risks (eg. coronary artery perforation during angiography), along with carrying a significant financial cost. The use of unnecessary preoperative testing can put the provider in violation of the principle of
nonmaleficence.
What is the principle that providers should take action for the benefit of others.
Beneficence
What are all the principles that support the position that medical mistakes must be disclosed to the patient.
Respect for autonomy
Nonmaleficence
Beneficence
Failure of which system when a nursel say “ he is a CEO of the hospital the next patient” that this information will engender a higher quality of delivered care.
failure in justice
Requires that all patients have the same moral claim to evidence-based quality health care.
The principle of justice
This includes both preventing harm and actively helping their patients.
Beneficence
Which principle underpins to the fundamental guiding principle of evidence-based interventions?
Beneficence
The benefits of the treatment should be demonstrable and must clearly outweigh the risks.
Beneficence
The principle that people under similar circumstances and conditions should be treated alike (also known as distributive justice).
Justice
Patients, despite differences in sex, age, race, ethnicity, education, sexual orientation, disability, geographic location, or socioeconomic status, should be treated fairly and equitably.
Justice
Informed consent conversations should include a discussion of
all available and appropriate anesthetic choices for both the particular surgery/procedure and relevant comorbidities.
It is recommended that the anesthesia consent process and paperwork should be
separate and apart from the surgical consent process; further,
The only appropriate person to conduct the anesthesia informed consent is the
anesthesia provider.
The preoperative consent process should allow for open sharing of information regarding
anesthetic care and focused on the patient’s concerns, needs, and question
What are the 6 elements of informed consent?
Competence Decision-making capacity Disclosure of information Understanding of disclosed information Voluntary consent Documentation
Why should you tell the patient your choice of anesthetic instead of theirs?
May be considered coercion, and puts the anesthetist at risk of litigation. Check your state law and institutional policy to determine whether the anesthesia informed consent must be signed by a witness and/or a translator if one is used.
Patient under age 18
Under most circumstances, parents or legal guardians are the competent party to consent.
Unless developmentally inappropriate, minor children should be included in the informed consent discussion and their agreement should be sought. This is termed
“assent” and should be documented.
In an emergency, when immediate treatment is required and the patient is unconscious or unable to consent, what law permits health care providers to provide lifesaving care.
“implied consent”.The emergency status must be documented in the medical record and informed consent should be sought from legal decision makers, or close family members, as soon as possible.
Informed Refusal states what? Give examples?
A patient has a right to refuse medical treatment or therapy. A common example is the refusal of blood or blood products by a Jehovah’s Witness. When a recommended therapy is refused, it places an even higher burden on the health care provider to disclose the risks and benefits of both the recommended and any alternative care.
In an elective case, a provider has no ethical obligation to provide inappropriate care, or care that is associated with
unreasonably high risks. Informed refusal should be documented as meticulously and carefully as informed consent.
When anesthesia providers are involved in the prenatal education process, the stresses of late term pregnancy are not yet influencing the learning and decision-making process. In addition, this provides
ample opportunity for patient and family questions about labor analgesia techniques and/or possible urgent and emergency situations.
For OB patients, written materials are recommended but do not replace the
requisite face-to-face discussion about the anesthesia plan of care.
OB patients Informed consent
Informed consent discussions should optimally occur prior to the onset of labor
Should be consulted when a minor is receiving obstetrical services.
State law and facility policies
May occur if a parturient refuses emergency care as a result of fetal distress.
Ethical conflict
In a case of maternal-fetal conflict, the provider’s respect for maternal autonomy may oppose what principle? What should the anesthetist do?T
principle of beneficence in promoting the well-being of the mother and the fetus. The anesthesia provider should keep communication open and non-coercive whilst procuring an ethics consultation, referencing hospital policy, and reviewing state law.
DNR and advance directive –>
ABecause many of these measures, when used in conjunction with a procedure/surgery, are temporary, it is recommended that advance directives be reconsidered before anesthesia is administered.
The AANA recommends that the patient, family, and health care team discuss reconsideration of advance directives during the informed consent process. s insufficient to simply tell the patient that institutional policy dictates how to proceed. In fact, policy language that dictates automatic suspension of advance directives during anesthesia or procedures should be rewritten with a more patient-centered approach.
An advance directive is a legally binding document that
delineates the patient’s wishes regarding healthcare interventions in the case of incapacity and/or delegates the authority to make healthcare decisions to another party.
Advance directives often include specific provisions that modify
aspects of anesthesia management including intubation, use of antibiotics, blood transfusion, and/or the use of CPR and advanced life support measures.
Just as informed consent must be documented, the reconsideration of advance directives discussion must also be documented:
Date and time of conversation with patient or legal representative.
Names of all parties present for the discussion.
Specific interventions to be modified or withheld including CPR, antibiotic use, intubation, and mechanical ventilation.
Specific duration of time for suspension or modification of directive.
Identify the standards of care that have been published by the American Association of Nurse Anesthetists.
Wellness
Infection Control and Prevention
Transfer of Care
The term malpractice refers to
any sort of professional misconduct. However, it is most frequently used in the setting of professional negligence, a subset of tort law.
In a negligence or malpractice claim, the patient (plaintiff) must prove 4 separate things:
- Duty
- Breach of Duty
- Causation
- Damage
- Duty -
the anesthesia provider had a duty to the patient
- Breach of duty -
the provider failed to fulfill their duty
- Causation -
a close causal relationship existed between the provider’s acts and the patient’s injury
- Damages -
actual damage was the result of a breach in the standard of care
2 main laws
Civil and criminal
What are the 2 parts of civil laws?
Contract and Tort law
3 parts of tort laws
Intentional
Strict Liability
Negligence
Examples of Tort law- intentional
Assault
Battery
Intentional infiltration of emotional distress
Examples of Tort law- Strict Liability
Defective products
Examples of Tort law- Negligence
Action was unreasonable unsafe
A duty to the patient is affirmed when
the anesthesia provider establishes a relationship with the patient during the preoperative assessment and informed consent process, and agrees to provide anesthesia care to the patient.
What is owed to the patient—the duty—is to
adhere to the standard of care necessary for the treatment plan. Courts generally support the notion that what a reasonable and prudent provider would do is defined by, and measured against, the national standards of care.
A breach of duty occurs when
But for or cause-in-fact—if the injury would not have occurred but for the actions of the provider, proximate cause is established
Substantial factor—if the act of the provider was a substantial factor in the injury despite other causes, proximate cause is established
expert witnesses review the medical record and determine that the standard of care was not adhered to.This could occur as a result of doing something that should not have been done, or by failing to do something that should have been done (this can be called an error of omission).
When is proximate cause established?
Generally, if the odds are greater than 50% that the breach of duty led to the injury, then proximate cause is established.
Tests used to determine causation include:
But for OR cause-in-fact
Substantial factor
But for or cause-in-fact—
if the injury would not have occurred but for the actions of the provider, proximate cause is established
Substantial factor—
if the act of the provider was a substantial factor in the injury despite other causes, proximate cause is established
Res Ipsa Loquitur means
Res ipsa loquitur (“the thing speaks for itself”) can shift the burden of proof from the plaintiff to the defendant.
4 conditions to establish Res Ipsa Loquitur
1) if the injury would not have occurred in the absence of negligence
2) the injury was caused by something under the complete control of the defendant (provider)
3) the patient did not contribute in any way to the injury, 4) the evidence for the explanation of events is solely under the control of the provider.
Classic examples of the use of this doctrine are cases of Res Ipsa Loquitur ?
Foreign object such as a sponge or a clamp inadvertently left in a surgical patient.
A nerve injury sustained during the course of surgery to an area remote from the surgical site is the second most common situation where a res ipsa charge request is usually granted.
What is defamation in the verbal form called?
Slander
What is defamation in the written form ?
Libel
After getting into an argument with a patient, a CRNA writes that the patient is “crazy” in the patient’s chart. This is a false statement, and it defames the patient’s character.
Libel
a CRNA intentionally writes a false statement in the patient’s chart (like charting an antibiotic that was never administered)
Libel
Discussing confidential patient information in a public location (such as a hospital elevator) is a key example of
HIPAA violation
Which standard relates to the accurate reporting of a patient’s condition which is defined as, “ Evaluate the patient’s status and determine when it is appropriate to transfer the responsibility of care to another qualified healthcare provider. Communicate the patient’s condition and essential information for continuity of care.”
Standard 11
These are torts aka
(civil wrongdoings)
What is the physical act of touching another person without either expressed or implied consent.
Battery.The key idea is that there’s direct physical contact.
______Is making a person feel or perceive that battery is imminent.
Assault . The key idea is that the victim is made to “feel” a certain way in response to your actions.
Assault cannot occur in
unconscious patients, because they’re unaware of their environments.
If you place an epidural in a laboring patient without her consent, then you’ve committed
battery.
If you’re preparing to place an epidural in this patient and she feels that you’re going to place it without her consent, then you’ve committed
assault.
A CRNA who administers a general anesthetic to a patient who has only consented for local by the surgeon (assuming no prior consent for GA was given) may be sued for battery.
Battery
Does not need to be proven when battery or assault charges are brought upon a provider.
Harm
What is statute of limitations?
Think of this as a deadline before which a patient must file a lawsuit. For example, if a patient is a victim of a tort and the statute of limitations is three years for this offense, then the patient can no longer sue after three years.
As a general rule, the statute of limitations for a minor doesn’t begin until t
he minor turns 18. For instance, if the statute of limitations for an offence is three years, then a minor will be able to file a lawsuit up to the age of 21 years (18 years + 3 years).
Viscarious liability
One person may be liable for the action of another
Respondeat superior means
Let the master answer
Punitive damages in these cases are very rare, since punitive damages are meant.
to punish the provider for engaging in either intentional harm or particularly reckless behavior
Special damages are from
Medical expenses
loss of income
property damage
General damages are
Pain and suffering etc.
Which law ensures public access to emergency services regardless of their ability to pay?
Emergency in Medical Treatment and Active Labor Act (EMTALA)
the federal law that prohibits the disclosure of individually identifiable health information (AKA personal health information, PHI). PHI includes past and present health conditions, treatments, and payments for health care
HIPAA
Example of Schedule I substance
Heroin
Example of Schedule II substance
Cocaine, barbiturate
Examples of Schedule III substance
Ketamine
Examples of Schedule IV substance
Tramadol
This act was intended to create a healthcare information technology infrastructure in order to improve care quality and coordination between providers, i.e. to promote the “meaningful use” of such information.
Health Information Technology for Economic and Clinical Health Act (HITECH)
ERISA sets minimum standards for private employee benefit plans, including the health care benefits offered, and provides protection for persons in these plans. These federal standards were written to ensure that the funds placed in retirement plans will be there when the individual employee retires!
Employment Retirement Income Security Act (ERISA)
Only after the patient’s care has been transferred to other qualified providers, or she/he has been pronounced, should you
begin preparing a post-critical incident report followed by talking to the family.
First, and before talking with the patient’s family, the provider should extensively document the events that occurred including:
What happened
What drugs and doses were given, and when they were given
The time sequence of events
Who was present (all parties, not just anesthesia)
During adverse action do not
Do not document speculation. Avoid documentation that is inconsistent with other sources.
State and institutional regulation or policy may direct
disclosure and/or apology to the family.
As noted in the Quality and Medical Error section (coming up soon), a patient who has been consented to risks should be afforded full disclosure if the risk becomes a reality. Communication should
be fact-based and conducted with empathy.
If very serious adverse events occurred, notify your
liability insurance carrier as well. Follow the patient’s hospital course carefully with daily assessments and notes, along with continued contact after discharge. Again, this strengthens your professional relationship with the patient and family.
The discovery phase of the lawsuit is
Gathering of facts, clarification, of issues that will be brought to trial
Deposition of the lawsuit is
Plaintiff and defense attorney will questions you. Testimony is under oath. then –> Settlement and trial
After discovery, even if you did nothing wrong, your insurer may elect
to settle the case. This is typically a financial decision, despite the intense emotional trauma that it will cause you. Generally, the insurer will only take the risk of going to trial when the damages are very high, and the defense case is exceptionally strong.
Rank the causes of anesthesia-related lawsuits from most common to least common.
Death
Nerve Damage
Permanent brain damage
Awareness
According to the data from the anesthesia closed claims project analysis of 10,500 cases in 2000, the most common injuries leading to malpractice claims are:
Death (30 percent)
Nerve damage (22 percent)
Permanent brain damage (10 percent)
Airway injury (6 percent)
Risks Associated with Increased Odds of Dying Within Seven Days of an Anesthetic
Physical status (3 – 5 vs 1 – 2): 10.65
Emergency vs elective surgery: 4.44
Major vs minor surgery: 3.82
Patient age (80 yrs vs < 60 yrs): 3.29
Among the 40 percent of claims made for death or permanent brain damage, the majority are due to airway management issues:
Inadequate ventilation (hypoxia, hypercarbia, or both) = 38 percent Esophageal intubation (unrecognized) = 18 percent Difficult intubation = 17 percent
Claims Made By Type Of Anesthesia Care
Almost 2/3 (65 percent) of claims are made regarding surgical anesthesia, with chronic pain procedures making up 18 percent, acute pain 8 percent, and obstetrical claims 9 percent.
The ethical basis for care of a pediatric patient comes down to two major points:
Who has the legal decision-making capacity—parent or pediatric patient?
What is in the best interest of the pediatric patient?
Emancipated minors are patients who are
patients younger than 18 years of age who are legally given the rights of an adult by a state court. Although variable by state law, criteria for emancipating a minor may include the fact that they are.
Emancipated minors examples:
Married
A parent, or is currently pregnant
In the military
Economically independent
Mature minors who are at least 14 years old are considered to be
Legally and ethically capable of giving informed consent, under specific circumstances if granted by a court. Typically, mature minors are only permitted to make low-risk decisions
Pregnant minors may need parental consent to have an abortion unless
Judicial bypass is sought and obtained. State laws on elective termination are complicated and vary considerably from state to state. As such, careful consultation with facility counsel is a prudent choice when faced with a pregnant minor.
The determination of whether to intervene founded on paren patriae is based on how harmful the parental decision may be to the patient. The assessment of either the chosen intervention or its absence should include these factors:
Amount of harm to the child
Likelihood of success
Overall risk to benefit ratio
Children of Jehovah’s Witnesses
Families should be informed that, despite all reasonable efforts to eliminate the need for transfusion, if an emergency occurs
a court order for transfusion will be sought. When the likelihood for transfusion is high, a court order should be sought prior to surgery.
With Jehovahs witness, In a life-threatening crisis, emergency transfusion should
be given prior to obtaining a court order. As these children approach maturity, they should be involved in the decision-making regarding the use of blood and blood products.
It is typically designed for analysis when performance falls below acceptable levels; at this point, provider and/or systems data are reviewed.
A quality assurance (QA) program
Examples of QA programs include
peer review systems, or morbidity and mortality reviews.
They recognize that errors will occur, and focus on the processes involved in both successes and failures. These data are analyzed and used to improve the process of care itself, not sanction or penalize individual providers.
Continuous quality improvement (CQI) programs identify opportunities for improvement
The CQI process has this key attribute recommended by the
1999 Institute of Medicine report To Err is Human: the implementation of a non punitive system for reporting and analyzing errors.
Outcome =
Change in health status after delivery of care
Process =
Planning and coordination of care activities
Structure =
Setting in which care is provided
Continuous quality improvement (CQI) programs 3 things
SOB
Structure, Outcome, Process
Which skill is central to and most essential for effective crisis resource management?
Communication
Anesthesia Crisis Resource Management: first 4
Know the environment.
Anticipate and plan. Be ready for the “worst case” scenario.
Call for help early. This step is widely supported in a culture of safety.
Exercise leadership and fellowship with assertiveness.
What proportion of anesthesia mishaps are estimated to occur as a result of human error?
70%
The most common reports of sleeping or sleep-related behavior during an anesthetic occur when working
16 or more continuous hours
During the night shift
What is the annual OSHA limit for workplace exposure to ionizing radiation in a 38-year old provider? (Enter your answer in rem)
5 rem
Formula for annual OSHA limit for workplace exposure to ionizing radiation
N-18) x 5 rem, N= age in years.
Average OR noise levels are ____and music can reach levels up to
77dB ; 105 dB.
The OSHA limit for an 8-hour span is______ and single noise levels should not exceed
90 dB; 115 dB
Tolerance definition
Markedly diminished effects of the same drug amount
Impairment definition
An inability to engage in activities of daily living
Withdrawal definition
Physical and emotional responses to very low drug levels
Estimated % of misusers
10 to 15 percent of all providers misuse drugs or alcohol at some point in their careers.
Identify the major goals of the Institute for Healthcare Improvement Triple Aim’s broad conceptual approach to improving health outcomes.
Improve patient experience
Improve population health
Reduce per capita costs
Patient-centered care is based on four concepts
Dignity and respect
Information sharing
Participation
Collaboration
